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Lucas Zier, MD, MPH; Douglas White, MD, MAS
Author and Funding Information

From the University of California-Berkeley and University of California-San Francisco Joint Medical Program (Dr Zier); and the Program on Ethics and Critical Care Medicine, Department of Critical Care Medicine (Dr White), University of Pittsburgh School of Medicine.

Correspondence to: Douglas B. White, MD, MAS, Associate Professor, Director, Program on Ethics and Critical Care Medicine, Department of Critical Care Medicine, University of Pittsburgh Medical Center, 3550 Terrace St., Scaife Hall, Room 608, HPU010604, Pittsburgh, PA 15261; e-mail: whitedb@upmc.edu


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;137(1):239. doi:10.1378/chest.09-1922
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To the Editor:

We thank Dr Pope for initiating a discussion about the normative ethical implications of our study recently published in CHEST (July 2009),1 which space limits did not allow us to pursue. He correctly points out that the ethical underpinnings of surrogate decision making require surrogates to set aside their own hopes and preferences for the patient and instead make decisions based on the substituted judgment or the best-interest standards. The aim of the study was not to examine this issue, and consequently our data are not helpful on this point. However, our data reveal that it is not rare for surrogates to hold religious objections to the futility rationale; therefore, further empirical research is needed to better understand how surrogates make treatment decisions when their religious or moral beliefs are at odds with the treatment course that seems most consistent with the patient’s preferences.

We agree that the ethical permissibility of overriding a surrogate’s treatment request generally hinges on whether the request is rooted in the surrogate’s own values or the patient’s values. When the treatment requested is rooted in the surrogate’s values, and those values differ from the patient’s, physicians have an ethical responsibility to ensure that the patient’s treatment preferences are respected. In our clinical experience, a careful, empathic discussion with the surrogate, often with the assistance of the hospital chaplain, can often help the surrogate understand and accept the need to respect the patient’s previously stated wishes. We have found this type of mediation to be considerably more fruitful than the alternative: time-consuming, adversarial legal proceedings to remove an individual as surrogate decision maker.

Zier LS, Burack JH, Micco G, Chipman AK, Frank JA, White DB. Surrogate decision makers’ responses to physicians’ predictions of medical futility. Chest. 2009;1361:110-117. [CrossRef] [PubMed]
 

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Zier LS, Burack JH, Micco G, Chipman AK, Frank JA, White DB. Surrogate decision makers’ responses to physicians’ predictions of medical futility. Chest. 2009;1361:110-117. [CrossRef] [PubMed]
 
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